UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Options to Purchase Common Stock | Â (1) | 07/31/2023 | Common Stock | 52,777 (2) | $ 5.94 | D | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Bauleke Christopher Scott 6600 WALL STREET MOBILE, AL 36608 |
 |  |  CEO of Healthland Holding Inc. |  |
/s/ J. Boyd Douglas, Jr., by power of attorney | 01/26/2016 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | All of the options are time-based options which, as of January 8, 2016, became fully vested. |
(2) | Received in connection with the merger of Healthland Holding Inc. into a subsidiary of the Issuer (the "Merger") in exchange for an employee stock option to acquire 1,603,619 shares of Healthland Holding Inc. common stock for $0.25 per share. Of the 52,777 options to purchase Issuer common stock issued to the reporting person in the Merger, 5,998 options are currently being held in escrow and are subject to forfeiture during the 15-month period following the Merger to satisfy indemnification payments and other payments that become payable to the Issuer pursuant to the merger agreement. |